Peripartum anaesthetic management of a parturient with spinal cord injury and autonomic hyperreflexia.

Abstract

I report a case of a parturient with spinal cord injury (SCI) who presented in early preterm labour with uterine-contractions-induced acute onset autonomic hyperreflexia and received combined spinal epidural analgesia (CSEA) for labour and an uneventful Caesarean section. A 17-year-old, 164-cm, 60-kg, gravida 1, para 0 female with SCI was admitted to the labour and delivery (L & D) suite at 36 weeks' gestation in preterm labour with regular uterine contractions, facial flushing, piloerection, headache and hypertension. She did not report any pain associated with her contractions. Her past medical history was significant for motor-vehicle-related cervical (C6−7) spinal cord transsection at 28 weeks' gestation. Anterior cervical fusions were performed under general anaesthesia in the immediate post-trauma period. At the time of the insult, the fetus suffered parenchymal brain injury and subsequently developed post-traumatic growth restriction. The patient had no known drug allergies. Her admission blood pressure was 145/90 mmHg, heart rate 60 beat.min−1 and respiratory rate 19 breath.min−1. Fetal heart rate was 140 beat.min−1 and reactive. The diagnosis of eclampsia was ruled out by routine laboratory studies (liver and kidney function tests). The working diagnosis of acute onset autonomic hyperreflexia was established and administration of labour analgesia was indicated. A CSEA with levobupivacane 2.5 mg combined with fentanyl 5 µg was promptly administered via a needle through needle technique (18-G Touhy-Schliff epidural needle, and a 27-G Pencan spinal needle) at the L3−4 vertebral interspace. A 20-G multi-orifice epidural catheter was inserted 4 cm into the epidural space. Aspiration from the epidural catheter was negative for blood and CSF. The decrease in the patient's blood pressure was recorded in approximately 4–5 min after the induction of labour analgesia. Over the next 5 min, her headache and other early symptoms of autonomic hyperreflexia subsided. Labour epidural analgesia consisted of a continuous infusion of levobupivacaine 0.0625% with fentanyl 2 µg.ml−1 at a rate of 8 ml.h−1. Six hours after the induction of CSEA, emergency Caesarean section was required for fetal distress. Surgical anaesthesia was established with incremental doses of chloroprocaine 3% to a total of 15 ml (450 mg) and fentanyl 50 µg administered through an epidural catheter. An uneventful Caesarean delivery of a female fetus weighing 2050 g, who had Apgar scores of 6 and 8, after 1 and 5 min, respectively, was accomplished. No postoperative complications were reported. Each year more than 2000 women of childbearing age in the United States alone sustain a SCI [1]. As a result of increased survival rates in women with SCI, the number of parturients with SCI is increasing [2]. Vaginal delivery is preferred. Any parturient with SCI whose level of transsection is at T6 or higher is at risk for acute autonomic hyperreflexia as a result of uterine contractions. Autonomic hyperreflexia in patients with SCI may be mistaken for pre-eclampsia at presentation [3]; consequently, routine laboratory studies (liver and kidney function tests) may be the key differential between the two disorders. Effective management includes prompt administration of labour analgesia. Because of rapid onset of labour analgesia, CSEA seems particularly suitable for these patients. Occurrence of preterm labour is not uncommon in parturients with SCI [4]. Early diagnosis is hampered by the inability of most quadriplegics to sense uterine contractions in the usual way. The incidence of pregnancy complications in parturients with SCI is increased, particularly when SCI occurs in pregnancy. The literature documenting peripartum anaesthetic management of pregnant patients with SCI is limited [1–5]. I am not aware of any reports documenting emergent administration of CSEA for parturients with SCI presenting in preterm labour with uterine-contractions-induced acute onset autonomic hyperreflexia. This case clearly demonstrates that expeditious induction of labour analgesia may prevent or ameliorate peripartum complications (including autonomic hyperreflexia) in labouring parturients with SCI.